Splenic Pathology in Traumatic Rupture of the Spleen: A Five Year Study

Hunaina Al-Kindi,1 Leena Devi,2 Mina George2

Al-Kindi H, et al. OMJ. 24, 81-83 (2009); doi:10.5001/omj.2009.19

ABSTRACT

Objectives: To Study the histopathology of spleens with a history of traumatic rupture with a view to establish possible predisposing factors to the rupture

Methods: This study examined the gross and microscopic features of consecutive cases of splenectomies done for traumatic rupture during a five year period in order to evaluate the presence or absence of any pathology prior to rupture.

Results: Of the 17 cases of splenectomy during this period, 14 were normal and 3 cases showed pathology other than rupture.

Conclusion: In the five year period of studying splenic pathology in traumatic rupture, 82% of the spleens showed normal histology except for the rupture. 18% of the cases showed different pathological findings on histopathology which could have contributed to the rupture.

From the 1Department of Histopathology, Khoula Hospital, Sultanate of Oman, 2Department of Pathology, Khoula Hospital, Muscat, Sultanate of Oman.

Rupture of the spleen can occur sponteneously or due to trauma. The incidence of traumatic rupture of the spleen increases due to rise in automobile accidents.1 Some studies have considered spleens affected by trauma to be normal and have used such spleens as control specimen in their studies.2 On the other hand, many studies have shown that there is an increased amount of white pulp in spleens from patients with traumatic injury.2,3,5 This has led to the speculation that in many cases of traumatic rupture, there could be a predisposing factor. In order to evaluate this in detail, this study reviewed the history and records of all splenectomy specimens received at the department of histhopathology from 1st January 2003 to 31 December 2007.

METHODS

Spleens were sent to the histopathology unit at Khoula Hospital following Road Traffic Accidents (RTA) during the period of 1st January 2003 to 31st December 2007. The age and sex of the patients and type of injury were noted. Size, weight and gross examination findings of the spleens including appearance of capsules, presence of rupture, hemorrhage or hematomas as well as a description of rest of the splenic pulp etc., were also noted (table 1).

Table 1: Patients and findings

No

Age

Sex

Type of injury

Size in cm

Wight (g)

Gross findings

Microscopic findings

1

28

M

RTA

8 x7 x 1.5

100

Breach of capsule and hemorrhage

Hemorrhage and neutrophilic infiltrate at the ruptured area

2

63

M

RTA

6 x 3.5 x 2.5

40

Breach of capsule and hemorrhage

Hemorrhage, Lymphoid follicle hyperplasia & amyloidosis

3

31

F

RTA

Not taken

70

Breach of capsule

Hemorrhage and neutrophilic infiltrate at the ruptured area

4

79

M

RTA

7 x 7.5 x 4

110

Breach of capsule and hemorrhage

Hemorrhage and neutrophilic infiltrate at the ruptured area

5

36

M

RTA

10x3x 5

100

Breach of capsule

Hemorrhage and neutrophilic infiltrate at the ruptured area

6

31

M

RTA

12x5.5

230

Breach of capsule and splenicule

Hemorrhage and neutrophilic infiltrate at the ruptured and splenicule

7

36

F

RTA

8x6x3

50

Breach of capsule

Hemorrhage and neutrophilic infiltrate at the ruptured area

8

46

M

RTA

12 x 7 x 3

120

Breach of capsule

Hemorrhage and neutrophilic infiltrate at the ruptured area

9

7

M

RTA

11 x 6 x 2.5

90

Breach of capsule

Hemorrhage and neutrophilic infiltrate at the ruptured and prominent malpigian corpuscle

No

Age

Sex

Type of injury

Size in cm

Wight (g)

Gross findings

Microscopic findings

10

4

M

RTA

8 x 7 x 2

50

Breach of capsule

Hemorrhage and neutrophilic infiltrate at the ruptured area

11

32

M

RTA

13 x 10 x 3.5

240

Breach of capsule and hemorrhage

Hemorrhage and neutrophilic infiltrate at the ruptured area

12

31

F

RTA

10 x 6 x 2.5

90

Breach of capsule and hemorrhage

Hemorrhage and neutrophilic infiltrate at the ruptured area and granuloma with calcific material

13

20

M

RTA

9 x 6 x 2.5

100

Breach of capsule, hemorrhage and well defined cream area

Hemorrhage and neutrophilic infiltrate at the ruptured area

14

35

F

RTA

10.5 x 7 x 3.5

120

Breach of capsule and hemorrhage

Hemorrhage and neutrophilic infiltrate at the ruptured area

15

27

M

RTA

6 x 5 x 2.3

40

Breach of

Hemorrhage and neutrophilic infiltrate at the ruptured area

16

25

M

RTA

9.5 x 6.5 x 3

110

Breach of capsule

Hemorrhage and neutrophilic infiltrate at the ruptured area

17

40

M

RTA

8.5 x 6 x 2.5

60

Breach of capsule

Hemorrhage and neutrophilic infiltrate at the ruptured and small non caseating granulomas

RTA: Road Traffic Accident; F: Female; M: Male

Hematoxylin and Eosin stained sections and sections with special stains, if any, were reviewed along with the given histopathology reports. Finally, an analysis of the findings was performed and was compared with the findings in published literature of similar studies.

RESULTS

During the period from 1st January 2003 to 31st December 2007, 17 cases of spleens removed for traumatic rupture were submitted for histological examination. All cases were involved in road traffic accidents. The comparatively low number of splenectomies during the 5 year period is due to the fact that most cases of blunt trauma of the abdomen are managed conservatively at the centre. 13 cases were from males and 4 cases from females. 10 of the cases were in 21-40 years age group (table 2).

Table 2: Age Incidence -17 Cases of Ruptured Spleen

Number of cases

Age

2

0-10

2

11-20

4

21-30

6

31-40

1

41-50

2

>50

Grossly, all 17 cases received showed breach of the capsule. In addition, 5/17 showed hemorrhage. While two cases showed perisplenitis.

Microscopically, all cases showed congestion of the red pulp and hemorrhage with neutrophilic infiltrate at the ruptured site. Multiple, small and discrete granulomas with calcified material were seen in one case. Small non-caseating granulomas were seen in another case. One case showed amyloid deposition with lymphoid follicle hyperplasia. While another case showed arteriosclerosis with calcification. In the rest of the cases, the rest of the pulp was unremarkable.

DISCUSSION

The spleen is the most commonly injured abdominal organ from non-penetrating injuries.1 Its location and anatomic features are primarily responsible for its susceptibility to injury from external forces.1 The aetiology of traumatic rupture of the spleen include automobile accidents, fall from a height or on level ground, blows and kicks, athletic injuries, gunshot wounds and others.1,3-5 The non traumatic causes of splenic rupture include; infectious mononucleosis, Acquired Immune Deficiency Syndrome (AIDS), malignancies, peliosis, granulomas and infarct.2-5

In this study, all 17 cases resulted from RTA in which the victims were either pedestrians or occupants of vehicles. The adult male in his second decade of life showed the greatest predisposition to this type of injury. The male to female ratio was 3.3:1. The age distribution and the gender follows closely to that reported in the literatures.1,4 In other studies it was found that the more physically demanding occupation and the greater exposure to trauma of young adult male accounts for these age and sex distribution.

Increased weight of the spleen was found to be an independent factor associated with rupture of the spleen.5 In this study, there was no significant increase in weight of the spleens. However, two cases showed increase in weight, clinically both patients were otherwise healthy at the time of RTA. In both cases, the histopathological findings were within normal limits except for the rupture.

Most of the spleens removed for trauma showed capsular laceration and hemorrhage. Microscopic findings included neutrophilic infiltrates at the lacerated site and in some cases, subcapsular infiltrates were also observed.6 Congestion and intraparenchymal hemorrhage were seen in most of the cases. Some studies found that the spleens removed following trauma to be normal.2 But a few other studies have shown that ruptured spleens exhibit follicular hyperplasiasuggesting the possibility of immune stimulation as a predisposing factor for splenic rupture following trauma.2,3,5 This has been clearly observed in Epstein-Barr Virus (EBV) infection, a recognized cause of splenic rupture and a potent stimulator of B cell proliferation in the spleen.3 However, in this study, only one case of lymphoid follicular hyperplasia was noted in a 63 year old male which was associated with amyloidosis (figure 1).

This could have facilitated splenic rupture as amyloidosis has been associated with spontaneous splenic rupture especially considering the fact that the spleen was not enlarged.7 Unfortunately, there were no follow ups recorded for the patient to look into other organ involvement by amyloidosis.

Multiple small discrete granlomas with calcific material were noted in a 13 year old female (figure 2). Clinically the patient was healthy at the time of RTA and expired one week later due to hypovolemic shock and severe head injury. Small noncaseating granulomas were also noted in another case for a 40 year old male, who is doing well. Non-caseating granulomas were described previously in spleens following blunt trauma.5

Pathological findings in similar previous studies included lipogranulomas, extramedullary hematopoiesis, subintimal hyaline deposits and infarction. However, no such lesions were encountered in this study.3,5

In the five year period of studying splenic pathology in traumatic rupture, 82% of the spleens showed normal histology except for the rupture. 18% of cases showed different pathological findings on histopathology which could have contributed to the rupture.

ACKNOWLEDGMENTS

The authors reported no conflict of interest and no funding has been received on this work.